Provider Demographics
NPI:1770816571
Name:TATE, JESSE JAMES
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:JAMES
Last Name:TATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 VARSITY DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8444
Mailing Address - Country:US
Mailing Address - Phone:910-520-2921
Mailing Address - Fax:
Practice Address - Street 1:610 VARSITY DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8444
Practice Address - Country:US
Practice Address - Phone:910-520-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health